capnography

I’ve only seen it used in the PICU. I don’t know the exact mechanics but I don’t think it’s quite as accurate with neonates plus it’s another device in between the ventilator and the baby- increasing the weight of tubing for higher chance of accidental extubation. The difference is that we don’t usually sedate babies like PICU and they weigh much less so the margin of error for intubation is much smaller, usually a couple of centimeters.

That's a good question. According to some studies, it seems like it's particularly difficult with sick neonates to measure ETCO2 due to the rapid respiratory rate. This article discusses pros and cons: https://pdfs.semanticscholar.org/ee1b/681dbcd06e9757cca6f6f24e9dee353043d4.pdf

That's my interpretation though. Thankfully I have never had to intubate an infant, hopefully won't have to. Lol

Thanks for your responses!

What do you guys think is the best way to monitor tube placement during transport of a neonate? In adults waveform capnography is great because you get an immediate alert if the tube is dislodged (i.e., into the hypopharanx). With little babies, it is obviously so much easier to dislodge an ET tube and not realize it. What do neonate transport teams use for monitoring?

2 hours ago, zzyzx said:

Thanks for your responses!

What do you guys think is the best way to monitor tube placement during transport of a neonate? In adults waveform capnography is great because you get an immediate alert if the tube is dislodged (i.e., into the hypopharanx). With little babies, it is obviously so much easier to dislodge an ET tube and not realize it. What do neonate transport teams use for monitoring?

I'll have to get back to you on that at work tomorrow! I think it is still a viable resource, just not as reliable in a pre term newborn. I'm just a lowly street medic, I've never been on a MICU transport unit. I'm interested to see the response.

Generally their vital signs tank and that’s how you know. Most babies sick enough to be intubated and transported don’t have much reserve. We did not use any special monitoring other than pulse ox and ekg when I did transport

We use them on neonates in our NICU and PICU. We use them for the purpose of trending CO2 and correlate it with routine gasses throughout the day and with any changes. We don't use them for confirmation of tube placement in the NICU, we do to an extent in the PICU but depending on the patient's disease state it is often not a great confirmation tool.

Keep in mind that on our smallest kids every bit of dead space counts, so the less you have between the patient's lungs and the vent or bag the better especially if you are not making any clinical decisions from the extra junk.

Preventing accidental extubations is a bit of a battle we have between our NICU and PICU, we take preemies in both units depending on their anatomy and disease process. Most of the accidental extubations are a result of inadequate sedation or restraint, even our micropremies are shockingly strong.

This becomes a bit of a double edge sword. In the PICU we certainly lean towards more sedation, more restraints, and more hands on care with our preemies. We have fewer accidental extubations, fewer code events, and better pulmonary outcomes. Our NICU has better neurological/developmental outcomes and much better bonding between preemies and parents (and sedation weaning isn't really a big problem for them). It does pain me every time I see one of our NNPs or neonatologists intubating a kid as they are moving and trying to avoid that very uncomfortable event.

As far as transport there is little reason why you could not give the vast majority of intubated neonates a dose of fentanyl and vec. Most neonates respond extremely well to fentanyl only sedation. If they are on a transport vent or being bagged (since we essentially exclusively use flow inflating bags) you will know very quickly if they become extubated. Neonates are generally easier to assess the effectiveness of ventilation compared to kids and adults anyway, so the need for end tidal monitoring just isn't as profound.